Provider Demographics
NPI:1790280758
Name:AMBER DENTAL PC
Entity Type:Organization
Organization Name:AMBER DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOEHNE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-665-5555
Mailing Address - Street 1:319 E ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-5526
Mailing Address - Country:US
Mailing Address - Phone:630-665-5555
Mailing Address - Fax:
Practice Address - Street 1:319 E ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-5526
Practice Address - Country:US
Practice Address - Phone:630-665-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019019448261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental